HospitalInspections.org

K-0025
Based on observation and staff interview, it was determined that the facility failed to maintain the fire resistance rating of the smoke barrier walls in accordance with the Life safety Code Section 19-3.7.3 and Section 8.3. This deficient practice could affect all patients through-out the building by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:
Smoke barrier wall penetrations were not maintained with a minimum 30 minute fire resistance rating as required. Smoke barrier wall penetration were deficient as follows:
1) Smoke barrier wall located in the Chiller room, was observed to have pipe penetration through the gypsum board on the walls and ceiling without fire rated sealant.

2) Smoke barrier wall in the Secure Central Supply room was observed to have pipe penetration through the gypsum board.

3) Smoke barrier wall in the Physicians lounge has an unsealed wire penetration.

The Hospital CEO and Director of Maintenance acknowledged the smoke barrier wall penetration during the tour of the facility.
Life Safety Code Section 19.3.7.3 requires that the smoke barrier wall be constructed in accordance with section 8.3, and shall have a fire resistance rating of not less than ½ hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.6.1 requires, in part, that the space between cable and pipe penetrations and the smoke barrier wall be filled with a material capable of maintaining the 30-minute fire resistance rating of the barrier.

K-0027
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the door opining on cross-corridor doors in accordance with the Life Safety Code Section 8.2.3.2.3.2. This deficient practice could affect all patients with in the smoke compartments through-out the building should the egress become untenable, due to smoke and heat transfer. This was evidenced by the following:
1) The double fire doors, located in the North and East wings on the second floor would not latch into the door frame during manual testing when released from the hold open device leaving a gap of excess of 1 inch.

2) Two fire rated doors in the Health Care Offices were installed on non-tagged rated frames, one going to two-hour Occupancies and to the fire rated corridor.

3) Fire rated door to the Central Supply room located in the OR was reconfigured from a full soiled rated door into a Dutch door and does not meet the requirements 19.3.6.3.

4) Anesthesia storage room located on the second floor is not equipped with self- closing device.

The Hospital CEO acknowledged the deficient smoke barrier doors during the tour of the facility.
19.3.6.3 Doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas shall be substantial doors, such as those constructed of 1 ¾ -in. (4.4 cm) thick, soiled-bonded core wood or of construction that resist fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

K0039
Through observation, during the survey it was determined that the facility failed to maintain the corridor free of obstructions. This deficient practice could affect all patients, staff and visitors through-out the building if condor is obstructed in a fire or other emergency. This was evidenced by the following:

Located outside the remodeled area in the corridor a temporary 4 ' x 4 ' floor to ceiling enclosed barrier and exhaust tube attached to the ceiling is obstruction the means of egress. The temporary exhaust tube was being utilized for positive air in a construction area located off of the corridor.

The Hospital CEO and Director of Maintenance acknowledged corridor obstruction during the tour of the facility.
Life Safety Code, Section 7.1.10.1 means of egress shall be continuously maintained free of obstruction or implements to full instant use in the case of fire or other emergency.

K0040

During the walk through of the facility, with the Hospital CEO and Maintenance Director, the facility failed to maintain delayed egress doors in accordance with the Life Safety Code Section 7.2.1.6.1. This deficient practice could affect all patients with in the smoke compartments through-out the second floor should the egress become untenable, due to smoke and heat transfer. This was evidenced by the following:

1) Nursery and stairwell exit doors lock when the " HUGS " system is activated and has no means of unlocking during a fire emergency.
2) One set of double egress doors from the OB and the stairwell door from the nurses ' station contained a keypad locking device on the door and the door did not contain delayed egress or access controlled locking on the door. Per section 19.2.2.2.4
3) ED delay egress door has a pre-alarm on the door.

The Hospital CEO and Maintenance Director acknowledged the means of egress door condition during a tour of the facility.
Life Safety Code Section 7.2.1.6.1 Delayed –Egress Locks
Where permitted in Chapters 12 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) Doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detectors of an approved supervised automatic fire detection system in accordance with Section 9.6

Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted."

K-0046
Based on record review of the emergency lighting testing during the survey, battery-powered emergency lights were not tested in accordance with Life Safety Code Section 7.9.3. This deficient practice could affect all patients and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:
No records of the emergency battery-back-up lighting (frogeye light) at the transfer switch and generator #1 was tested in accordance with Life Safety Code 7.9.3, 19.2.9.1.
The Hospital CEO and Maintenance Director acknowledge the required testing of the emergency light during a tour of the facility.
Life Safety Code, Section 7.9.3 A fictional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

K0050
Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect all patients when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following:
Fire drills were not conducted quarterly on second shift, as required. A review of the fire drill records indicated the following work shifts without fire drills conducted:
2nd. Shift fire drills were not conducted for the 3 rd. Quarter of 2015.
All shifts fire drills were not conducted for the 4th. Quarter of 2015. One drill was conducted in the 4th quarter with no time documented on form, it cannot be counted as one of the shifts.
The Hospital CEO Administrator and Maintenance Director acknowledge the lack of fire drills deficiency during record review of the facility.
Life safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

K0051
Through observation and testing, during the survey it was determined that the facility failed to provide a fire alarm system with approved components and devices. This deficient practice could affect all patients and staff throughout the facility in the event of a fire emergency. This was evidenced by the following:
The facility contained a waiting room in the x-ray area, which measured 238 sq. ft. in size. This room was open to the corridor and did not contain smoke detection.
The Hospital CEO Administrator and Maintenance Director acknowledge the lack of the smoke detector deficiency during the tour of the facility.
Life Safety Code, Section 9.6.1.4. A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code.

K-0062

Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.

(1) A pendent-head sprinkler in the kitchen dish-room shows evidence of excessive corrosion.
(2) Two (2) pendent-head sprinkler located in the public dining area shows evidence of being painted.
(3) Main Entrance door a pendent-head sprinkler shows evidence of being painted.
(4) Obstructed concealed sprinkler head in the X-ray room #3.
(5) Boiler room sprinkler gauge at the riser was non-functional.
(6) Cancer Center and OR sprinkler gauges at the risers are dated 2009, no records or documentation of the sprinkler gauges being calibrated or replace occurred every five (5) years.
(7) Logan storage room is missing its escutcheon plate.
(8) No records or documentation of a full trip system test on the dry system.

The Hospital CEO and Maintenance Director acknowledge the deficiency of the maintenance of the sprinkler system during the facility tour.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5 Per NFPA 13 section 3-2.6.3 " Unless applied by the manufacturer, sprinklers shall not be painted, and any sprinklers that have been painted shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution. "

K0070
Based on observation and staff interview it was determined that the facility failed to maintain fire safe environment in the Administration Offices. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated space heaters. This was evidence by the following.

Two (2) non- documented approved rating space heaters were located in the Administration office. These devices could not be verified that the heating element does not go above 212 degrees.

The Hospital CEO and Maintenance Director acknowledge the deficiency of the prohibited space heaters during the facility tour.
Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all heath care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee ' s areas where the heating elements of such devices do not exceed 212° F (100° C).

K0074
Through observation and record review during the survey, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated curtains. This was evidence by the following.
(1) Central Scheduling room has one (1) untreated or tagged drapery.
(2) Nursery has one (1) untreated or tagged drapery.

The Hospital CEO and Maintenance Director acknowledge the deficiency of the draperies during the facility tour.
Life Safety Code 10.3.1. Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decoration shall be flame resistant as demonstrated by testing in accordance with NFPA 701, standards Methods of Fire test for Flame Propagation of Textiles and Films.

K0077
During the walk through of the facility, with the Maintenance Director, two(2) areas contained emergency shut off valves without separation between the area it controls and the shut off valve per NFPA 99 4-3.1.2.3: This deficient practice could affect all patients in the ED. This was evidence by the following.

Two (2) gas valve located at the nurses station controlling rooms one through nine (1 through 9), the emergency shutoff valves that controlled these area was without separation between the room and shutoff valves.
The Maintenance Director acknowledge the deficiency of the emergency shutoff valves during the facility tour.
NFPA 99, Section 4-3.1.2.3 Gas Shutoff Valves. Gas shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable window large enough to permit manual operation of valves.

K144
Based on observation, staff interview, and record review during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 6 This deficient practice has the potential to affect all patients, staff and visitors in the event of power loss. This was evidenced by the following.

The facilities generators #1 and 2 is not equipped with a remote stop station. All level I and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

The emergency power supply system deficiency item was discussed with the Hospital ' s CEO and Director of Maintenance.

K0147
Based on observation and staff interview during the survey, it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association 70, National Electrical Code. This deficient practice could affect all patients in the Administration smoke compartments due to increased potential hazards of electrical fire.

Located in the Administration office and extension cord was spliced into and a j-box to supply power from a duplex receptacle to an office cubical.

The Maintenance Director acknowledge the deficiency of the electrical wiring during the facility tour.

Electrical wiring and equipment shall be in accordance with National Electrical Cod. 9-1.2 (NFPA99) 18.9.1, 19.9.1.

K-0211

Through observation during the survey, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly. This deficient practice could affect all residents within the CT room.
K0211
Located in CT room an Alcohol Based Hand Rub dispenser was installed directly above a duplex receptacle.

The Director of maintenance acknowledged the improper installation of the Alcohol Based Hand Rub dispenser during the facility tour.

Per Chapter 19, section 19.3.2.7(6) "The dispensers shall not be installed over or directly adjacent to an ignition source."

K-0025
Based on observation and staff interview, it was determined that the facility failed to maintain the fire resistance rating of the smoke barrier walls in accordance with the Life safety Code Section 19-3.7.3 and Section 8.3. This deficient practice could affect all patients through-out the building by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:
Smoke barrier wall penetrations were not maintained with a minimum 30 minute fire resistance rating as required. Smoke barrier wall penetration were deficient as follows:
1) Smoke barrier wall located in the Chiller room, was observed to have pipe penetration through the gypsum board on the walls and ceiling without fire rated sealant.

2) Smoke barrier wall in the Secure Central Supply room was observed to have pipe penetration through the gypsum board.

3) Smoke barrier wall in the Physicians lounge has an unsealed wire penetration.

The Hospital CEO and Director of Maintenance acknowledged the smoke barrier wall penetration during the tour of the facility.
Life Safety Code Section 19.3.7.3 requires that the smoke barrier wall be constructed in accordance with section 8.3, and shall have a fire resistance rating of not less than ½ hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.6.1 requires, in part, that the space between cable and pipe penetrations and the smoke barrier wall be filled with a material capable of maintaining the 30-minute fire resistance rating of the barrier.

K-0027
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the door opining on cross-corridor doors in accordance with the Life Safety Code Section 8.2.3.2.3.2. This deficient practice could affect all patients with in the smoke compartments through-out the building should the egress become untenable, due to smoke and heat transfer. This was evidenced by the following:
1) The double fire doors, located in the North and East wings on the second floor would not latch into the door frame during manual testing when released from the hold open device leaving a gap of excess of 1 inch.

2) Two fire rated doors in the Health Care Offices were installed on non-tagged rated frames, one going to two-hour Occupancies and to the fire rated corridor.

3) Fire rated door to the Central Supply room located in the OR was reconfigured from a full soiled rated door into a Dutch door and does not meet the requirements 19.3.6.3.

4) Anesthesia storage room located on the second floor is not equipped with self- closing device.

The Hospital CEO acknowledged the deficient smoke barrier doors during the tour of the facility.
19.3.6.3 Doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas shall be substantial doors, such as those constructed of 1 ¾ -in. (4.4 cm) thick, soiled-bonded core wood or of construction that resist fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

K0039
Through observation, during the survey it was determined that the facility failed to maintain the corridor free of obstructions. This deficient practice could affect all patients, staff and visitors through-out the building if condor is obstructed in a fire or other emergency. This was evidenced by the following:

Located outside the remodeled area in the corridor a temporary 4 ' x 4 ' floor to ceiling enclosed barrier and exhaust tube attached to the ceiling is obstruction the means of egress. The temporary exhaust tube was being utilized for positive air in a construction area located off of the corridor.

The Hospital CEO and Director of Maintenance acknowledged corridor obstruction during the tour of the facility.
Life Safety Code, Section 7.1.10.1 means of egress shall be continuously maintained free of obstruction or implements to full instant use in the case of fire or other emergency.

K0040

During the walk through of the facility, with the Hospital CEO and Maintenance Director, the facility failed to maintain delayed egress doors in accordance with the Life Safety Code Section 7.2.1.6.1. This deficient practice could affect all patients with in the smoke compartments through-out the second floor should the egress become untenable, due to smoke and heat transfer. This was evidenced by the following:

1) Nursery and stairwell exit doors lock when the " HUGS " system is activated and has no means of unlocking during a fire emergency.
2) One set of double egress doors from the OB and the stairwell door from the nurses ' station contained a keypad locking device on the door and the door did not contain delayed egress or access controlled locking on the door. Per section 19.2.2.2.4
3) ED delay egress door has a pre-alarm on the door.

The Hospital CEO and Maintenance Director acknowledged the means of egress door condition during a tour of the facility.
Life Safety Code Section 7.2.1.6.1 Delayed –Egress Locks
Where permitted in Chapters 12 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) Doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detectors of an approved supervised automatic fire detection system in accordance with Section 9.6

Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted."

K-0046
Based on record review of the emergency lighting testing during the survey, battery-powered emergency lights were not tested in accordance with Life Safety Code Section 7.9.3. This deficient practice could affect all patients and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:
No records of the emergency battery-back-up lighting (frogeye light) at the transfer switch and generator #1 was tested in accordance with Life Safety Code 7.9.3, 19.2.9.1.
The Hospital CEO and Maintenance Director acknowledge the required testing of the emergency light during a tour of the facility.
Life Safety Code, Section 7.9.3 A fictional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

K0050
Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect all patients when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following:
Fire drills were not conducted quarterly on second shift, as required. A review of the fire drill records indicated the following work shifts without fire drills conducted:
2nd. Shift fire drills were not conducted for the 3 rd. Quarter of 2015.
All shifts fire drills were not conducted for the 4th. Quarter of 2015. One drill was conducted in the 4th quarter with no time documented on form, it cannot be counted as one of the shifts.
The Hospital CEO Administrator and Maintenance Director acknowledge the lack of fire drills deficiency during record review of the facility.
Life safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

K0051
Through observation and testing, during the survey it was determined that the facility failed to provide a fire alarm system with approved components and devices. This deficient practice could affect all patients and staff throughout the facility in the event of a fire emergency. This was evidenced by the following:
The facility contained a waiting room in the x-ray area, which measured 238 sq. ft. in size. This room was open to the corridor and did not contain smoke detection.
The Hospital CEO Administrator and Maintenance Director acknowledge the lack of the smoke detector deficiency during the tour of the facility.
Life Safety Code, Section 9.6.1.4. A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code.

K-0062

Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.

(1) A pendent-head sprinkler in the kitchen dish-room shows evidence of excessive corrosion.
(2) Two (2) pendent-head sprinkler located in the public dining area shows evidence of being painted.
(3) Main Entrance door a pendent-head sprinkler shows evidence of being painted.
(4) Obstructed concealed sprinkler head in the X-ray room #3.
(5) Boiler room sprinkler gauge at the riser was non-functional.
(6) Cancer Center and OR sprinkler gauges at the risers are dated 2009, no records or documentation of the sprinkler gauges being calibrated or replace occurred every five (5) years.
(7) Logan storage room is missing its escutcheon plate.
(8) No records or documentation of a full trip system test on the dry system.

The Hospital CEO and Maintenance Director acknowledge the deficiency of the maintenance of the sprinkler system during the facility tour.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5 Per NFPA 13 section 3-2.6.3 " Unless applied by the manufacturer, sprinklers shall not be painted, and any sprinklers that have been painted shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution. "

K0070
Based on observation and staff interview it was determined that the facility failed to maintain fire safe environment in the Administration Offices. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated space heaters. This was evidence by the following.

Two (2) non- documented approved rating space heaters were located in the Administration office. These devices could not be verified that the heating element does not go above 212 degrees.

The Hospital CEO and Maintenance Director acknowledge the deficiency of the prohibited space heaters during the facility tour.
Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all heath care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee ' s areas where the heating elements of such devices do not exceed 212° F (100° C).

K0074
Through observation and record review during the survey, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated curtains. This was evidence by the following.
(1) Central Scheduling room has one (1) untreated or tagged drapery.
(2) Nursery has one (1) untreated or tagged drapery.

The Hospital CEO and Maintenance Director acknowledge the deficiency of the draperies during the facility tour.
Life Safety Code 10.3.1. Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decoration shall be flame resistant as demonstrated by testing in accordance with NFPA 701, standards Methods of Fire test for Flame Propagation of Textiles and Films.

K0077
During the walk through of the facility, with the Maintenance Director, two(2) areas contained emergency shut off valves without separation between the area it controls and the shut off valve per NFPA 99 4-3.1.2.3: This deficient practice could affect all patients in the ED. This was evidence by the following.

Two (2) gas valve located at the nurses station controlling rooms one through nine (1 through 9), the emergency shutoff valves that controlled these area was without separation between the room and shutoff valves.
The Maintenance Director acknowledge the deficiency of the emergency shutoff valves during the facility tour.
NFPA 99, Section 4-3.1.2.3 Gas Shutoff Valves. Gas shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable window large enough to permit manual operation of valves.

K144
Based on observation, staff interview, and record review during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 6 This deficient practice has the potential to affect all patients, staff and visitors in the event of power loss. This was evidenced by the following.

The facilities generators #1 and 2 is not equipped with a remote stop station. All level I and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

The emergency power supply system deficiency item was discussed with the Hospital ' s CEO and Director of Maintenance.

K0147
Based on observation and staff interview during the survey, it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association 70, National Electrical Code. This deficient practice could affect all patients in the Administration smoke compartments due to increased potential hazards of electrical fire.

Located in the Administration office and extension cord was spliced into and a j-box to supply power from a duplex receptacle to an office cubical.

The Maintenance Director acknowledge the deficiency of the electrical wiring during the facility tour.

Electrical wiring and equipment shall be in accordance with National Electrical Cod. 9-1.2 (NFPA99) 18.9.1, 19.9.1.